HomeMy Public PortalAbout5733AGNES AVE_Plumbing (2) WORKERS' COMPENSATION DECLARATION APKICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW a/87
7
CE 81
sure,or a cgertificate of Wotkers'CompensationCE 81Insurance,or a (
7(REV. 8/86)
certifiedt,copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST
' CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB '
COMPENSATION INSURANCE SHOWER OWNER {
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.
as to•become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you'should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER,HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter / GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fed Professions Code, and my license is in full force and ef- 5 PER,SYSTEM FINAL DATE VALIDATION
�f
License Number Lic. Class O_ V
FINAL 0
Contractor Date BY O
I am exempt under Sec.
81P.C. for this reason.
• Plan check fee g
Date: PLUMBING PERMIT ISSUING FEE $ AI �)
Signature
TOTAL FEE Q
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
r a
Low for the following reason (Section 7031.5, Business and ' -� � � �� _ _.; >a
Professions Code): Address '�aJ-' 6C65- .41
- v
I Wit
��as`owner of theproperty, will do the work and the City c Tel. No.
����c;'C�
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). _N.
CONSTRUCTION LENDING AGENCY , I' ' K a te}
I hereby affirm that there is a construction.lending agency for _
the performance of the work for which this permit is issuedig3 of f
(Sec. 3097, Civ. C.).
Lender's Name i_it J.
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County ,
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-me 'oned prop rt y for inspection purposes..
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig turelof Permittee Date